Case 1: Perfusion Challenges Sahil A. Parikh, MD, FACC, FSCAI - PowerPoint PPT Presentation

SCAI 2019 May 22, 2019 Case 1: Perfusion Challenges Sahil A. Parikh, MD, FACC, FSCAI Associate Professor of Medicine Director, Endovascular Services Center for Interventional Vascular Therapy New York-Presbyterian Hospital Columbia University Irving Medical Center Columbia University Vagelos College of Physicians and Surgeons

Disclosures Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Company • TriReme Medical, Shockwave Medical, • Grant/Research Support NIH, Surmodics, Silk Road Medical (CEC); Boston Scientific (DSMB) • Consulting Fees/Honoraria • Terumo, Abiomed • Abbott, Boston Scientific, Medtronic, CSI, • Advisory Board Philips

Perfusion Challenges • 91 year old man • T:36.6 HR: 75 BP: 131/65 • Former smoker, HTN, HL • RR: 17 SpO2: 100% • CAD s/p CABG • Gen: NAD • Prior GIB • Heart: RRR S4s1 s2 • Rest pain in bilateral legs x 2-3 years • Chest: CTA &P • Two months prior – bilateral LE wounds • Abd: Soft nt nd, no bruit • Right leg wound healed • Extr: warm, trace edema B/l, + femoral • Left leg – heel wound (1cm) and L medial malleolar ulcer bruits bilaterally, Doppler monophasic • Currently living alone with little help DP/PT bilaterally • L heel 1cm shallow ulcer and L medial malleolar venous appearing ulcer

Patient MB • WBC 8.1 Meds • Hgb 10.6 • ASA 81 mg daily • Atorvastatin 20 mg daily • Hct 31.0 • Losartan – HCTZ 50-12.5 mg daily • Terazosin 2 mg daily • Cr 0.9 • Pantoprazole 40 mg daily • INR 1.1 • Plt 212 SH • Quit smoking 20 years ago • 50+ pack year history • Now using wheelchair, previously walker

ABI/PVR FINDINGS: Resting: RIGHT LEFT Brachial 165 mmHg 162 mmHg Thigh 95 mmHg 85 mmHg Calf 89 mmHg 112 mmHg DP 69 mmHg 73 mmHg PT 0 mmHg 94 mmHg Toe 25 mmHg 35 mmHg DP ABI 0.42 0.44 PT ABI 0.00 0.57 TBI 0.15 0.21

Doppler U/S FINDINGS: Right Right Left Left ARTERIES Velocity Waveform Velocity Waveform Aorta 91.8 cm/s Biphasic Common Iliac 194.0 cm/s Monophasic External Iliac 119.0 cm/s Monophasic Common Femoral 234.0 cm/s Continuous 88.7 cm/s Triphasic Profunda 17.0 cm/s Biphasic 113.4 cm/s Triphasic Superficial Femoral (prox) 68.0 cm/s Continuous 122.0 cm/s Continuous Superficial Femoral (mid) 170.0 cm/s Tardus/Parvus 243.0 cm/s Continuous Superficial Femoral (distal) 37.0 cm/s Tardus/Parvus 41.5 cm/s Continuous Popliteal 56.0 cm/s Tardus/Parvus 48.9 cm/s Continuous TP Trunk 70.9 cm/s Tardus/Parvus 9.0 cm/s Tardus/Parvus Anterior Tibial 16.6 cm/s Tardus/Parvus 13.0 cm/s Monophasic Posterior Tibial 0.0 cm/s Occlusion 49.6 cm/s Tardus/Parvus Peroneal 41.0 cm/s Tardus/Parvus 0.0 cm/s Occlusion

Diagnostic Angiogram

Diagnostic Angiogram

Runoff

Now what? • What access? • What vessels will be treated? • Are patients with venous insufficiency treated differently? • How do we cross the CTO of the SFA and PT? • What definitive therapies are needed? • How do we define success?

Wire Loop Crossing

Subintimal Balloon

Outback

IVUS IVUS shows deep subintimal position with dissection flap. True lumen near popliteal

Shockwave 1

Shockwave 2

Post Shockwave/Balloon

Post PTA

Peroneal/PT

Post-DCB Angioplasty Angiography

Final angiography after Supera Stents

Final Angios

Intervention Summary • R CFA Access with 7F crossover access • CTO crossing, Outback re-entry • Dilation with PTA and Shockwave • DCB and tibial PTA • Supera Stents from pop-mid-SFA • Restoration of palpable pulse

Epilogue • L heel wound almost healed in 6 weeks • L malleolar venous ulcer improved with compression and wound care • L ABI 0.95. No rest pain • R ABI 0.48. No rest pain.